Enhabit Hospice

“Based on observation, interview, and record review, the hospice failed to protect and promote the exercise of each patient’s rights for 1 of 3 (Patient #2) patients reviewed in that: The hospice failed to ensure each patient’s right to receive effective symptom control for 1 of 3 (Patient #2) patients reviewed in that RN K failed to coordinate care with a hospice physician and/or the hospice administrator on call in order to ensure provision of effective interventions to treat Patient #2’s symptoms of shortness of breath and difficulty breathing during the time-period from the evening of 11/01/25 to the morning of 11/02/25, when the patient was pronounced deceased. (Refer to L512).”

“Based on observation, interview, and record review, the hospice failed to ensure each patient’s right to receive effective symptom control for 1 of 3 (Patient #2) patients reviewed in that: RN K failed to coordinate care with a hospice physician and/or the hospice administrator on call in order to ensure provision of effective interventions to treat Patient #2’s symptoms of shortness of breath and difficulty breathing during the time-period from the evening of 11/01/25 to the morning of 11/02/25, when the patient was pronounced deceased. This failure resulted in physical harm to Patient #2 who was not comfortable in the hours prior to his death due to symptoms of shortness of breath and difficulty breathing. The findings included: Record review of Intake #2664476, dated 11/08/25, included allegations which indicated that on Saturday night (11/01/25) Patient #2 was struggling to breathe. The intake indicated the hospice nurse was contacted and indicated upon arrival the hospice on-call nurse seemed “ready to leave as soon as she possibly could.” The intake indicated the hospice nurse administered anxiety medication and Hydrocodone and advised the family to call her if anything changed. The intake indicated the medications were not effective and the patient continued to struggle to breathe. The intake indicated the family called the on-call nurse and requested for her to return to the home. The intake indicated during one of the visits the hospice on-call nurse mentioned the comfort pack (a pack or kit containing several medications commonly provided to hospice patients to control symptoms that often occur at the end of life which usually includes medications such as Lorazepam (an anxiety medication which can be used to treat shortness of breath and difficulty breathing) and Morphine (a medication used to treat pain, shortness of breath, and difficulty breathing) which are often provided in advance of the patient experiencing symptoms to prevent delays in treatment when symptoms develop) and was attempting to determine which medication to replace the Morphine with as the patient was allergic to the Morphine. The intake indicated the nurse said she was ordering the comfort care pack to be picked up the following morning (11/02/25), but the patient did not live through the night. The intake indicated the patient expired that night after “struggling to breathe for hours.” The intake indicated the comfort care pack was not provided and indicated oxygen was also not provided for the patient. The intake indicated the patient was not comfortable or at peace prior to his death and indicated the patient expressed to the family that he could not breathe before becoming unresponsive. The intake indicated, “It was a special kind of torture seeing [the patient] struggle to breathe knowing you couldn’t [sic] do anything for him and the people that were supposed to be there to help him did nothing for him!” Record review of the clinical record for Patient #2 included a plan of care, for the certification period of 10/22/25 – 01/19/26, which indicated the patient had a start of care date of 10/22/25 and a diagnosis of malignant neoplasm of the colon (cancer of the digestive system). The plan of care indicated the patient was to receive skilled nurse visits twice a week for thirteen weeks, and then once a week for one week. The plan of care indicated the hospice nurse could provide up to 5 PRN (as needed) visits for symptoms including shortness of breath. The plan of care indicated, “Patient may have hospice comfort pack as ordered by physician … Skilled nurse to observe and assess respiratory system [lungs and airways] … Goals … Hospice comfort pack will be provided to the patient (Patient/Caregiver) will verbalize/demonstrate understanding of appropriate use of medications in comfort pack. Skilled nurse will assess effectiveness of implementation of comfort pack medications in the palliation [relief] of symptoms and management of the terminal illness at end-of-life …” The plan of care indicated that the patient had an allergy to Morphine. Record review of a coordination note, dated 11/01/25 at 9:30 p.m., indicated Patient #2’s family called and reported the nurse had been present at the patient’s home a little time before the call, but the patient was experiencing labored breathing (difficulty breathing, requiring additional effort to breath), and the family requested a second nurse visit. The note indicated a second nursing visit was to be completed. Record review of a second coordination note, dated 11/02/25 at 12:02 a.m., indicated Patient #2’s family called and reported they believed the patient had died. The note indicated a nurse visit was scheduled. Record review of a third coordination note, dated 11/02/25 at 6:31 a.m., indicated Patient #2’s family called and reported they believed the client had passed. The note indicated a nurse visit was scheduled. Record review of a discharge summary note, dated 11/02/25, indicated the patient had died. Record review of the clinical record for Patient #2 indicated the patient’s Family Member #1 was listed as his only contact. Record review of a PRN skilled nurse’s note, dated 11/01/25, from 10:04 p.m. to 11:27 p.m., signed by RN K, indicated the Patient #2’s respirations were at 19 breaths per minute (the normal rate for adults is usually between 12 and 20 breaths per minute) and “labored.” There was no documentation of an oxygen saturation level (a measurement of the amount of oxygen in the blood) obtained during this visit. The note indicated the patient had dyspnea (difficulty breathing) at rest and with activity (indicating the difficulty breathing was not fully relieved with rest) and had “severe” breathlessness. The note indicated that the patient was allergic to Morphine and did not have Morphine present in the home. The note indicated alternate “needs” (sic – meds) to be ordered. The note indicated the patient was moved up in bed, the head of his bed was elevated, a fan was placed in the room and Hydroxyzine (a medication used to treat anxiety) was administered to assist with anxiety and shortness of breath. The note indicated after 30 minutes the shortness of breath was improved but not relieved entirely. The note did not indicate the physician was contacted or alternative medications were ordered/requested for the patient’s shortness of breath and difficulty breathing. The note did not indicate oxygen was ordered or requested. Record review of a second PRN skilled nurse’s note, dated 11/02/25 from 8:35 p.m. to 9:10 p.m. (the time of the visit documented on this note was incorrect as the note was not generated until after the visit was completed), signed by RN K, indicated Patient #2’s respirations were at 24 and “labored.” The note did not indicate the oxygen saturation level was obtained during this visit. The note indicated the patient’s eyes were “bulging out.” The note indicated the patient was using accessory muscles to breathe (the patient was using additional muscles to assist with the work of breathing – a symptom seen when an individual is experiencing difficulty breathing and requiring additional work of the body to breathe) and was experiencing dyspnea at rest and with activity. The note indicated the patient had “very very severe breathlessness (almost maximum).” The note indicated the patient had, “noisy labored breathing, long period of hyperventilation [faster than normal rate of breathing], cheyne stokes respirations [an irregular breathing pattern of very deep rapid breathing, then short breaths, followed by a period of no breathing].” The note indicated the patient’s facial expression was “sad frightened frown.” The note indicated Hydrocodone (a prescription pain medication) was administered during the visit. The note indicated the patient’s family member who had called the hospice’s on-call number reported she believed the patient had died but upon the skilled nurse’s arrival the patient was alive but experiencing severe dyspnea. The note indicated the Hydroxyzine was not yet due (the amount of time ordered by the physician to wait between administering doses of the Hydroxyzine had not yet expired) and the nurse advised the family to administer the next dose when next due. The note did not indicate the physician was contacted and did not indicate oxygen was requested/ordered or indicate alternative medications to treat the shortness of breath and difficulty breathing were ordered/requested. The note did not indicate if the administration of the Hydrocodone was effective in treating the dyspnea/shortness of breath. Record review of a skilled nurse death visit, dated 11/02/25, signed by RN K, indicated the patient died on this date and his death was pronounced by RN K at 7:25 a.m. The surveyor attempted to contact Patient #2’s Family Member #1 on 11/20/25 at 8:47 a.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a second attempt to contact Patient #2’s Family Member #1 on 11/20/25 at 1:58 p.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a third attempt to contact Patient #2’s Family Member #1 on 11/21/25 at 12:16 p.m. There was no answer. A voicemail message was left requesting a return phone call. There was no return phone call received from Family Member #1 prior to the end of the investigation. During an interview conducted on 11/20/25 at 8:57 a.m., RN H said she no longer worked for the hospice and said she had last worked for the hospice about three weeks prior to 11/20/25. RN H said she had last provided care to Patient #2 about six weeks prior to 11/20/25. RN H said she completed the patient’s start of care assessment and was his RN Case Manager for a time. When asked regarding the hospice’s process for identifying and addressing medication allergies at the start of care, RN H said Patient #2 was alert and oriented and his Family Member #1 was present during the start of care visit, and they were both able to verify the patient’s allergies. RN H said she believed the patient was allergic to Morphine. RN H said she could not recall what reaction the patient had to receiving Morphine. RN H said Morphine was part of the comfort pack medications, but the staff could alter the comfort pack medications if needed if the patient had an allergy and would notify the physician of the allergy and the physician would order an alternative medication. RN H said the comfort pack and Morphine were not in the patient’s home when she was providing care to the patient of which she was aware. RN H said for Patient #2, as he was allergic to Morphine, the hospice could substitute the Morphine with Fentanyl (a type of prescription pain medication) and said the hospice could notify the physician of the allergy and discuss substituting with Fentanyl and request orders from the physician because of the allergy prior to ordering the comfort pack. When asked if this process was followed for Patient #2, RN H said the patient was tolerating his pain pretty well. RN H said the patient had a PEG tube (a medical tube surgically inserted into the digestive tract to administer medications/feedings/fluids for individuals who were unable to take these in orally) and the medications were administered through his PEG tube because taking medications orally caused him significant nausea. RN H said due to this signification modifications to the medications in the comfort pack had to be made for Patient #2. RN H said another RN took over the patient’s care prior to the patient’s death. RN H said during the time she was the RN Case Manager for Patient #2 the patient did not have a comfort pack or Fentanyl in the home. RN H said the patient did have Hydrocodone in the home. RN H said the patient did not have any breathing issues while she was providing his care. When asked if there were other options to control shortness of breath/dyspnea for a patient with an allergy to Morphine, RN H said, yes, there were other options the hospice could provide. RN H said the hospice could try Fentanyl, Ativan (a medication used to treat anxiety), and could try several different combinations of medications to attempt to obtain a similar effect as would be seen with the Morphine if the patient was allergic to the Morphine. RN H said if a patient were experiencing significant shortness of breath and/or dyspnea/breathing difficulty, and was allergic to Morphine, she would notify the physician of the situation and request new orders for other interventions. RN H said her understanding was that if the patient/family requested oxygen or the patient showed signs of needing oxygen, such as struggling to breathe, using accessory muscles to breath, or the oxygen saturation level not maintaining while on room air (while not receiving supplemental oxygen), even after trying Morphine and secondary options with medications the hospice could add oxygen. RN H said the hospice nurse could request an order for the oxygen and get it delivered as quickly as possible and said if the medications could be picked up locally the nurse could order to a local pharmacy and pick up and deliver the medications. RN H said the hospice preferred to order medications through the secure pharmacy which delivered medications but that took overnight, usually 1-2 days, for the medications to be delivered. RN H said if the patient had an urgent need the hospice nurse could pick up the medications more quickly from a local pharmacy if needed but said not all areas had a pharmacy that was open twenty-four hours a day/seven days a week and said she did not believe there was a pharmacy located in the area where Patient #2 resided that was open twenty-four hours a day/seven days a week. RN H said some of the pharmacies in the area did open early. When asked what the hospice nurse would be expected to do/what the process was if the patient had an urgent need, but the nurse was unable to access necessary medications or oxygen, RN H said she would assess the situation, determine what the patient had available, and contact the physician to determine what could be done with the medications the hospice had available. When asked regarding the hospice’s process for providing a comfort pack to a patient to ensure medications were available if an urgent need arose, RN H said for patients residing in a private home, such as Patient #2, how quickly the comfort pack was provided would depend on if the patient appeared to be relatively imminent (close to death), such as death was likely in the next 30 days, and said the nurse would monitor the patient for changes and if they noted the patient to be declining the nurse would let the physician know and the comfort pack would be ordered. RN H said it was based on the patient’s clinical condition and said this was the guidance she received from the hospice leadership regarding when to order the comfort pack medications. RN H said it could potentially be an issue if the patient declined quickly over a short period of time and the medications were not in the home because the nurse/family/patient might not be able to obtain the medications quickly enough if there was an urgent need such as after close of business of pharmacies in the area. RN H said she did receive training from the hospice regarding symptom and medication management on hire and ongoing throughout her time employed with the hospice. During an interview conducted on 11/20/25 at 10:00 a.m., RN K said she only provided services to Patient #2 during the weekend of his death (from the evening of 11/01/25 to the morning of 11/02/25) and said that Saturday (11/01/25) was the first time she had seen/cared for Patient #2. When asked regarding the visits conducted with Patient #2 on 11/01/25 and 11/02/25, RN K said the patient was having shortness of breath. RN K said the patient had requested to get up in his chair and the family had attempted to get him up and he became very short of breath at that time. RN K said the patient did not have the comfort pack medications in the home at that time, so she administered the Hydroxyzine to assist with the breathing/anxiety, elevated the head of his bed, placed a fan in the room, and advised him to try to calm down and relax. RN K said she did not know the reason the patient did not have the comfort pack medications in the home on 11/01/25. RN K said the comfort pack medications were usually ordered at the start of care. RN K said she did text the Hospice Medical Director during that visit (on 11/01/25) because the patient was allergic to Morphine (which was typically a medication included in the comfort pack to treat shortness of breath and difficulty breathing) so that she could get medications ordered and they could be picked up the following morning (11/02/25). RN K said there was no pharmacy open at the time of the visit. RN K said she did not receive a response from the Hospice Medical Director until 7:30 a.m. the next morning (on 11/02/25) asking if she still needed the replacement medication for the Morphine. RN K said by that time the patient had already passed away. RN K said she usually received a response right away when contacting the Hospice Medical Director, but the text she (RN K) sent was pretty late at night, at 11:18 p.m. (on 11/01/25), and that was probably why it took a longer time to get a response from the Hospice Medical Director. RN K said the next visit she completed with the patient (during the time-period of 11/01/25 and 11/02/25) was because the family believed the patient had passed away. RN K said the family had transferred the patient to his chair again and believed he had died. RN K said when she arrived the patient was alive but “very, very short of breath.” RN K said during the visit the patient was experiencing significant shortness of breath. RN K said the shortness of breath was “pretty severe,” and said the patient did not have much energy, had difficulty breathing/shortness of breath with rest and with activity, and was having difficulty speaking due to the shortness of breath. RN K said the patient was not complaining of difficulty breathing or shortness of breath, but he was not really responding. RN K said the patient’s eyes were open and he was “kind of staring.” RN K said the patient was using accessory muscles to breathe at that time. RN K said she was not able to obtain an oxygen saturation level during any of the visits on 11/01/25 or 11/02/25 despite attempts to obtain them. RN K said she would usually document in her skilled nurse’s note if she had attempted to contact the physician or attempted to obtain the oxygen saturation level and if it was not documented for Patient #2, she probably just forgot to document it. When asked if she attempted to call the physician back or to contact a supervisor or alternate physician as she had not received a response from the Hospice Medical Director and the patient was experiencing symptoms, including difficulty breathing and shortness of breath, RN K said, “No, I did not.” RN K said she did administer Hydrocodone to the patient during one visit and stayed awhile after administering the medication. RN K said the patient did seem to calm down a little but looked like he was getting closer to passing away and was not as responsive. When asked regarding the hospice’s process/expectation for what a nurse should do if the physician had not responded and the patient was experiencing symptoms not controlled with the medications/interventions available, RN K said the process/expectation was for the nurse to call the administrator on call. When asked if she had contacted the administrator on call regarding Patient #2, RN K said, no. When asked the reason she did not contact the administrator on call, RN K said there was “no reason” that she had not done so. RN K said the symptoms had improved some, but the patient was still experiencing shortness of breath/dyspnea at the time she left the home. RN K said the patient had Hydrocodone and Hydroxyzine in the home and had no other medications for her to attempt. RN K said the comfort pack medications were not available in the home. RN K said the patient did not have oxygen in the home. When asked if she had attempted to order the oxygen, RN K said no and said at the time her mind was on the comfort pack, and she had tunnel vision regarding that. RN K said the visit was late at night and she had limited resources available. RN K said she had never been in the situation of needing to order oxygen after business hours and did not know if she would have been able to obtain it if needed. RN K said there was no pharmacy open in the area to obtain other medications to treat the patient’s shortness of breath and difficulty breathing and to use the hospice’s usual pharmacy would take additional time and she would not be able to obtain the medications that night. RN K said the nurses usually checked each visit to ensure the comfort pack was available in each patient’s home and she didn’t know why it was not there for Patient #2 prior to the visits on 11/01/25 and 11/02/25 as he had not been her patient, and she had not seen him before 11/01/25. RN K said if the patient had an allergy to a comfort pack medication the nurse would request an order from the physician for an alternative medication. When asked regarding interventions she implemented to address the patient’s symptoms, RN K said during one visit she administered Hydroxyzine and on another she administered Hydrocodone. RN K said she sat the patient up in bed, elevated the head of the bed, and placed a fan in the room. RN K said she noted some improvement in the symptoms before leaving the home, but the patient was still experiencing some shortness of breath/dyspnea at the time she left the home. RN K said when she left the home her expectation was that she would obtain new orders for medications the next day, but the patient passed away before she could do so. RN K said if a patient’s symptoms were not relieved sufficiently by the interventions/medications available in the home at the time of the visit the expectation was for the nurse to call the physician or the administrator on call to obtain further instructions. RN K said she did not call the physician or the administrator on call for Patient #2 and said the reason was that she thought she had done everything she could do under the circumstances. RN K said she had received training from the hospice regarding symptom/medication management and said she was trained regarding the medications included in the comfort kit, what they were for, and which symptoms they treated, and to ensure there was some improvement in the symptoms before leaving the home. RN K said she was trained by the hospice to contact the physician or administrator on call before leaving the home, if unsure what to do. RN K said she received this training on hire with the hospice as part of her orientation. RN K said it was the responsibility of the nurse making the visit to ensure the training/policies/hospice processes were followed each visit. RN K said she did discuss the events with Patient #2 on 11/01/25 – 11/02/25 with RN D/Branch Director after the patient’s death (on 11/03/25) and said she suggested that the comfort pack should be in each patient’s home in advance in the future and RN D/Branch Director agreed. During an interview conducted on 11/20/25 at 11:27 a.m., RN K said the visits with Patient #2 which she documented as having completed on 11/01/25 and 11/02/25 took place between the evening/night of 11/01/25 and the early morning of 11/02/25. During an interview conducted on 11/20/25 at 12:00 p.m., RN D/Branch Director said the nurses who provided care to Patient #2 were supervised by herself and the Administrator/Supervising Nurse. RN D/Branch Director said she received report from RN K after the patient’s passing (on 11/03/25) and said RN K reported the hospice did not have the comfort pack medications available in Patient #2’s home on 11/01/25 and 11/02/25. RN D/Branch Director said RN K said she was able to administer Hydrocodone to give the patient as much comfort as possible. RN D/Branch Director said she thought RN K was trying to provide as much comfort as possible with what she had available. When asked the reason the comfort pack medications were not available in Patient #2’s home, RN D/Branch Director said she did not know and said after the patient’s death, the next day (11/03/25), she made it a point to train all staff to ensure a comfort pack was maintained in each patient’s home. RN D/Branch Director said she also had one of the hospice RN Case Managers assist her to order comfort packs for each current patient and educated staff on available pharmacies that were open twenty-four hours a day seven days a week. RN D/Branch Director said there were not any close to the patient’s home [in Town #1] but there was one in [City #1] nearby that was open twenty-four hours a day seven days a week that could have been utilized. RN D/Branch Director said in a situation such as the one that occurred with Patient #2 on 11/01/25 to 11/02/25, she would expect the nurse to contact the DME company (a company that provides medical equipment including oxygen) and order oxygen. RN D/Branch Director said she would also expect the nurse to continue to try to call the physician if she had not received a response. RN D/Branch Director said the nurse could also contact the Administrator on Call if she needed something for a patient and was unable to reach the physician. RN D/Branch Director said there was one pharmacy the nurse could have used to get the patient medications during the time-period of the evening of 11/01/25 to the morning of 11/02/25 if she had received an order from the physician. RN D/Branch Director said the hospice had a physician on call twenty-four hours a day seven days a week and said she was usually able to reach the physician quickly when needed. RN D/Branch Director said she believed if the hospice had ensured the comfort pack medications were available in the home with an alternate medication for the Morphine available to treat shortness of breath/dyspnea the hospice could have prevented the issues experienced by Patient #2. RN D/Branch Director said the nurse could have administered the Lorazepam (a medication used to treat anxiety which can assist with difficulty breathing) or an alternative medication for shortness of breath/dyspnea to the patient if the medications had been available in the home. During an interview conducted on 11/20/25 at 12:45 p.m., the Hospice Medical Director said if the patient was unable to take the Morphine and was experiencing shortness of breath/dyspnea the hospice could try to administer a Benzodiazepine (a class of medications used to treat anxiety and insomnia), such as Lorazepam or Ativan (a medication used to treat anxiety), which sometimes helped or she could try to dig in to determine if there were other medications the patient was not allergic to such as Dilaudid (a type of prescription pain medication) or Tramadol (a type of prescription pain medication) which might work. The Medical Director said just because the patient was allergic to one Opioid (a class of prescription pain medications) medication did not necessarily mean he was allergic to all of them. When asked if she was notified of the patient’s condition on 11/01/25 to 11/02/25, the Medical Director said she did not recall. The Medical Director said the usual process was the nurse would send her a text message and would follow up with a phone call if they needed something from her right then. The Medical Director said if it were something she needed to address right away, and the nurse did not receive a response to a text message and needed an order she would expect the nurse to call. The Medical Director said not every situation required the nurse to wake her up in the middle of the night. The surveyor explained the situation with Patient #2, as reported and documented by RN K, regarding the significant shortness of breath/dyspnea, and the medications/interventions in the home not being fully effective, and the Medical Director said it sounded reasonable for the nurse to call her (the Medical Director) in that situation. The Medical Director said the hospice had a backup physician who oversaw her (the Medical Director) who was a regional medical director and there was a second physician on the team who could also be contacted if a nurse was unable to reach her (the Medical Director) for a patient need. The Medical Director said if there was no pharmacy available to obtain different medications for the patient she might have recommended additional doses of the medications which were in the home until the pharmacy opened. The Medical Director said she might have ordered oxygen but was not sure of the availability or how quickly the oxygen would have been delivered late at night. During an interview conducted on 11/20/25 at 3:38 p.m., the Administrator/Supervising Nurse said if the patient had an allergy to a medication ordered in the comfort pack an alternative medication could be ordered, such as Oxycodone (a type of prescription pain medication) or Dilaudid. The Administrator/Supervising Nurse said she thought they had discussed Hydrocodone as an alternate medication for Patient #2. When asked if there were alternative medications to the Morphine that could be ordered for shortness of breath/dyspnea, the Administrator/Supervising Nurse said if the patient were allergic to Morphine the hospice would usually order Dilaudid instead. The Administrator/Supervising Nurse said the Dilaudid was not ordered for Patient #2. The Administrator/Supervising Nurse said no other patients had experienced adverse outcomes related to the issues with medication/symptom management and said there were no other current hospice patients who had allergies to the comfort pack medications. The Administrator/Supervising Nurse said the hospice had one other patient who was admitted 11/19/25 who had an issue with dyspnea/shortness of breath, but this patient was not allergic to the comfort pack medications, including the Morphine. The Administrator/Supervising nurse said it was of “high importance” to ensure allergies were identified and addressed and to ensure that if the medication included in the comfort pack could not be administered that the hospice identified another medication that could be administered to treat symptoms. The Administrator/Supervising Nurse said staff received training on hire and throughout their employment with the hospice regarding medication/symptom management, allergies, and how to address concerns in those areas. The Administrator/Supervising Nurse said in the situation where a patient was allergic to a comfort pack medication the nurse should immediately contact the physician for another medication to treat the symptoms and said Patient #2 should have received the comfort pack with the alternate medication to the Morphine at the start of care. The Administrator/Supervising Nurse said the hospice should have addressed the allergy and ensured another medication to treat the symptoms was ordered and present at the start of care. The Administrator/Supervising Nurse said the hospice’s policies, processes, and trainings regarding medication/symptom management and allergies were not followed for Patient #2. When asked why the hospice’s policies, processes, and trainings regarding medication/symptom management and allergies were not followed for Patient #2, the Administrator/Supervising Nurse said, “I have no idea.” The Administrator/Supervising Nurse said she did not know why the patient did not receive the comfort pack with the alternative medication to Morphine at the start of care. The Administrator/Supervising Nurse said if a patient was experiencing severe dyspnea/shortness of breath the process/expectation was that if the patient had Morphine available in the home the nurse would administer it or administer oxygen, sit the patient up and assist with positioning for easier breathing, and if the patient did not have medications or oxygen needed to treat the symptoms to contact the physician and request orders. The Administrator/Supervising Nurse said if the patient could not take Morphine and was experiencing shortness of breath/dyspnea the expectation would be for the nurse to contact the physician and obtain orders for an alternative medication. The Administrator/Supervising Nurse said she had not had a chance to review the nurse’s notes for the visits conducted on 11/01/25 and 11/02/25 by RN K or to discuss the issues during those visits with RN K. The Administrator/Supervising Nurse said the hospice had a contract with their DME company that oxygen would be delivered within two hours of the request if needed and had a contracted pharmacy that would go out at night to deliver the medications, after business hours, and the medications to treat Patient #2’s shortness of breath and dyspnea could have been received by Patient #2 if they had been ordered. The Administrator/Supervising Nurse said she was not informed of the incident at the time it occurred. The Administrator/Supervising Nurse said she would look for documentation on the retraining of staff and of the staff ordering comfort packs for the patients after the incident with Patient #2 as reported by RN D/Branch Director and would provide that to the surveyor. The Administrator/Supervising Nurse said the issues with RN K failing to ensure Patient #2’s symptoms of dyspnea and shortness of breath were adequately treated were not identified by the hospice until after the surveyor’s entry for the investigation. The Administrator/Supervising Nurse said the hospice had an alternate medical director and a regional medical director who could have been contacted by RN K if she was unable to reach the Hospice Medical Director and RN K could have contacted the Administrator on Call if she was not getting a response from a physician and said as the patient had orders for the comfort kit already in place on the plan of care the nurse could have had those medications filled without even contacting the physician for an order and could have provided those medications, including Lorazepam, which could have assisted with the patient’s symptoms even if she was not able to reach a physician that night. During an interview conducted on 11/20/25 at 3:55 p.m., the Administrator/Supervising Nurse said RN K was the weekend on-call nurse and was not scheduled to see patients until Friday (11/21/25) night but would not be allowed to provide care to any hospice patients until additional training was provided. The Administrator/Supervising Nurse said she had confirmed the time on the PRN skilled nurse’s note, dated 11/02/25 from 8:35 p.m. to 9:10 p.m., signed by RN K, was incorrect due to the note being generated after the visit was conducted and the visits with Patient #2 were conducted between the evening/night of 11/01/25 and the morning of 11/02/25. During an interview conducted on 11/20/25 at 4:35 p.m., the Administrator/Supervising Nurse provided documentation of training provided by the hospice on 11/03/25 regarding ensuring comfort pack medications were present in all patients’ homes and documentation that comfort pack medications were ordered for current patients who did not have them already present in the home on 11/03/25. The Administrator/Supervising Nurse also provided documentation of training completed on 11/20/25, regarding hospice policies regarding patient rights, coordination of care, patient death, symptom management, and what to do if a physician did not respond when contacted. The documentation indicated that the hospice nursing staff, including RN K attended this training. The Administrator/Supervising Nurse said RN K had attended the training on 11/20/25 and would also be coming into the office on 11/21/25 for additional in-person training which would be completed prior to her being allowed to provide additional care to hospice patients. The Administrator/Supervising Nurse said training was provided to the hospice staff on 11/03/25 regarding ensuring comfort pack medications were provided to each patient and present in the home at the start of care and said on 11/03/25 the hospice ensured all current patients who did not already have a comfort pack present in the home had one ordered. Record review of hospice in-service training documentation, dated 11/03/25, signed by RN D/Branch Director, indicated on this date the hospice provided education to the hospice nursing staff regarding ensuring all patients had comfort packs in the home. Record review of hospice pharmacy order documentation, dated 11/03/25, indicated the hospice ordered comfort pack medications to be delivered to current patients who did not already have the comfort pack present in the home. Record review of hospice in-service documentation, dated 11/20/25, indicated training was provided to the hospice nursing staff regarding hospice policies regarding patient rights, coordination of care, patient death, symptom management, and what to do if a physician did not respond. The documentation indicated that the hospice nursing staff, including RN K, attended this training. During an interview conducted on 11/21/25 at 9:15 a.m., the Administrator/Supervising Nurse said on 11/20/25 it was reported all current patients had the comfort pack medications available in their homes, but the hospice had determined there were four patients who did not currently have all the comfort pack medications in the home, Patient #5, Patient #7, Patient #8, and Patient #9. The Administrator said none of these patients were currently experiencing any symptoms requiring these medications. The Administrator/Supervising Nurse said Patients #7, 8, and 9 all had the major medications from the comfort kit including Morphine and Lorazepam. The Administrator/Supervising Nurse said Patient #5 was a transfer from another hospice in another state and had previously been on the services of the hospice being surveyed and was provided with the comfort pack at that time but when he transferred back from the hospice in the other state that hospice did not send the comfort pack medications back with him. The Administrator/Supervising Nurse said the comfort packs for these patients had all been ordered and would be delivered tomorrow (11/22/25). The Administrator/Supervising Nurse said she did train all nursing staff yesterday regarding the after-hours pharmacy (After-Hours Pharmacy #1) contracted with the hospice to provide medications twenty-four hours a day seven days a week and the DME company contracted to provide oxygen within 2 hours after normal business hours, and how to contact a physician, including the backup physicians, and how and when to contact the administrator on call if the nurse had concerns with a patient requiring symptom management after normal business hours to ensure medications could be provided to all patients even if the comfort pack was not available in the home. During an interview conducted on 11/21/25 at 9:37 a.m., RN D/Branch Director said she attended the hospice nurse training on 11/20/25 and said they discussed ensuring comfort packs were available for all patients and what to do if the comfort pack was not available RN D/Branch Manager said the staff were informed that After-Hours Pharmacy #1 was the hospice’s contracted pharmacy if medications were needed outside normal business hours and were available to fill prescriptions twenty-four hours a day seven days a week. RN D/Branch Manager said the hospice training also covered how to contact the medical director, the alternate medical director, and a third contracted medical director if the nurse was unable to reach the Hospice Medical Director in a timely manner. RN D/Branch Manager said the hospice training also covered how to contact the administrator on call and that the staff could always call the Administrator/Supervising Nurse if they were unable to reach anyone else. RN D/Branch Director said at the end of each day she sent out a report to the nursing staff and on the report yesterday (11/20/25) she included the phone numbers for the Medical Director and the alternates to the medical directors, the on-call nurse, the administrator on-call, the name and phone number for After-Hours Pharmacy #1, and how to contact these individuals/companies for assistance, if needed, for the reference of the nurses. During an interview conducted on 11/21/25 at 10:00 a.m., the Administrator/Supervising Nurse said RN K had completed the training with the rest of the nursing staff yesterday (11/20/25) and had been informed of what to do if medications were needed after hours and would be receiving additional in-person training on 11/21/25 to ensure that she was fully aware of how to address concerns and access necessary medications/supplies/equipment and to get questions answered if needed after hours prior to being allowed to return to caring for patients. The Administrator/Supervising Nurse said RN K was on call this weekend but would not be allowed to see patients until all the in-person training was completed. During an interview conducted on 11/21/25 at 10:27 a.m., RN F said she had attended the hospice training on 11/20/25 and the training covered following the chain of command if a patient needed something and the Hospice Medical Director could not be reached, that the staff could call the backup medical director, and they also had a third contracted medical director who could be contacted and that the staff could also contact the administrator on call, RN F said the hospice had a contract with a pharmacy to provide medications twenty-four hours a day seven days a week, After-Hours Pharmacy #1, who could provide medications if needed outside normal business hours and a contracted DME company for oxygen or equipment if needed after hours and provided the information for those individuals/companies for the reference of the nursing staff. During observations conducted on 11/21/25, from 10:30 a.m. – 12:00 p.m., visits were conducted with Patients #4, 5, and 6. Patients #4, 5, and 6 were observed to demonstrate no signs or symptoms of pain, respiratory distress, or other uncomfortable symptoms and the patient/family/facility staff did not report any concerns. Patients #4 and 6 were observed to have the comfort pack medications in the home and available for use if needed. Patients #4, 5, and 6 were all observed to have oxygen in the home and available for use. Patient #5 did not have the comfort pack medications present but was not observed to have any symptoms of pain, discomfort, or difficulty breathing/respiratory distress. The patient and family reported no concerns or current needs (per previous interview conducted on 11/21/25 at 9:15 a.m., with the Administrator/Supervising Nurse, Patient #5 was to have the comfort pack medications delivered by 11/22/25). During an interview conducted on 11/21/25 at 12:18 p.m., RN K said she had attended the hospice training yesterday and said the training covered the hospice’s policies and procedures and what to do if the nurse was unable to reach the Hospice Medical Director. RN K said the training covered the contracted DME company which was contracted to get oxygen to the patient’s home within two hours of the request and the hospice’s contracted pharmacy, After-Hours Pharmacy #1, which was contracted to provide medications twenty-four hours a day seven days a week. RN K said the hospice discussed that if Hospice Medical Director was not able to be contacted the hospice could contact the backup medical director and the third contracted physician for ordersif needed and provided information on how to contact those individuals/companies. RN K said she was to attend additional retraining in person at the hospice office on 11/21/25 but felt comfortable regarding the training and understood the expectations and policies and procedures and what to do if the situation should recur. During an interview conducted on 11/21/25 at 1:37 p.m., RN E said she was able to attend the training held by the hospice on 11/20/25 and said they discussed who the nurse was to call if the patient needed medications which were not available in the home. RN E said the nurse could call the Hospice Medical Director and if they were not available the hospice had two backup medical directors who could be contacted. RN E said the hospice could use the contracted pharmacy to obtain medications twenty-four hours a day seven days a week. RN E said if she needed oxygen for a patient, she would call the contracted DME company, and it would be delivered. RN E said she had no concerns or questions and felt comfortable with the expectations and processes. Record review of a hospice policy titled, “Patient rights,” dated 2000, last revised 07/23/25, indicated, “Statements of rights are written documents … which identify the patient’s rights to … Exercise these rights at any time as a patient of the Agency … To have an appropriate ... management of pain and other symptoms … The Agency protects and promotes the exercise of patient rights …””